National Imaging Associates, Inc. (NIA)1

Post Service Therapy Management Trainingfor Home State Health Plan

Provider Training

Presented by: Leta Genasci

1National Imaging Associates, Inc. (NIA) is a subsidiary of Magellan Healthcare, Inc.

1. Program Description

2. Process Overview

3. Provider Support and Contact Information

Program Agenda

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Therapy Management Post Service Review Program Description

Targeted Procedures:

Procedures to be Reviewed:

Physical Therapy Occupational Therapy Speech Therapy

The review is focused on therapy services performed:

Outpatient Office

Outpatient Hospital

Skilled Nursing Facility

Home Health

Clinical Objectives:

Rehabilitative – Acute Episode Management

Habilitative – Management of episodic care through development

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Effective February 1, 2018 Home State Health Plan will collaborate with NIA to evaluate Physical, Occupational and Speech Therapy services for medical necessity.

Components of the Therapy Management Post Service Review Program

Notification

Analysis

Clinical Records

Records Review

Final Adjudication

Program notification about new review process for Physical, Occupational and Speech Therapy to applicable provider network.

Claims are processed and possibly pended for records for to be reviewed.

Records submitted are reviewed by an NIA Peer clinical reviewer.

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If pended, clinical records for therapy services requested from the Provider.

Home State Health Plan may deny some or all of the claims payments based on the results of the review process.

Process Overview

Post Service, Pre Adjudication Review Process

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Claim forwarded

to NIA

Claims subject to

proprietary UM algorithm

Clean

PendRecords requested & reviewed

Medical Necessity Determination Made

• Peer clinical review using licensed and nationally recognized guidelines

• Outreach to discuss case and ongoing care plan

• Service deemed medically unnecessary or clinically inappropriate denied after additional peer-to-peer offered and attempted

Treatment rendered

• No prior authorization prior to rendering services• Clinical algorithms that identify cases for review are driven by real-time data and analytics• Clinical Review process conducted by specialty matched peer clinical reviewers

Returned to Planfor Payment

Therapy Management

Expert Account Management

Comprehensive patient and provider level approach: clinically-based algorithm incorporates provider and patient demographics to identify cases requiring clinical validation

Appropriate Intensity, Frequency and Volume of services: underutilization or overutilization of services, visit content and frequency; right care, right place, right time.

Duplication and coordination of services: seeing multiple same discipline therapists or both PT and OT and coordination between providers

Billing practices: ensure compliance with appropriate billing practices, including out of scope, revenue inflation and/or unbundling

Expertise in managing the quality and appropriate utilization of therapy services

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Process Steps

Claims Submitted

• Claims will be sent to Home State Health Plan with applicable therapy modifiers (GP/GN/GO).

• Claims will be submitted to NIA for review of appropriateness of care/medical necessity.

Records Requested

• Claims may pend for clinical records based on clinical indicators.

• Records can be uploaded to www.radmd.com or faxed to NIA at 800-784-6864.

• NIA peer clinical reviewers will make a final determination of medical appropriateness of past and potential future services within a given episode of care.

• Medical necessity determination is based on established clinical guidelines in concert with plan and state requirements.

Claims Adjudicated

• Home State Health Plan providers and members will be notified of final determinations.

• Claims will be adjudicated based on final determination; including the potential for denied claims if medical necessity criteria is not met or requested clinical records are not received in a timely manner for review.

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Clinical Documentation Required for Reviews

• Pertinent therapy records including the initial evaluation, treatment notes, and a recent progress note.

• Documentation such as progress notes and/or a discharge summary from a recent or concurrent episode of care.

• All documentation must comply with Clinical Guideline: Record Keeping and Documentation Standards.

• This includes, but is not limited to:

• inclusion of appropriate patient history, diagnosis, prognosis and rehab potential

• objective tests and measures

• treatment goals and a plan of care including frequency and duration of services provided

Additionally, these items must be updated on a regular basis and included as part of a therapy progress note.

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Clinical Documentation Submission

Fax with Fax Cover Sheet

Internet UploadProviders who have access to the internet can upload records via NIA’s secure, HIPAA-compliant portal www. RadMD.com.

Providers can fax medical records using the Fax Cover Sheet supplied with the Records Request.

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The NIA Therapy reviewer will make one of thefollowing determinations:

The services met criteria* (approved) The services did not meet criteria* (denied) No clinical information was received in order to

make a determination (Insufficient Information –administratively denied).

The plan will finalize claims payment based on these determinations:

Did not meet medical necessity criteria Had no records submitted Approved

Review Results

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* Procedures will be evaluated based on clinical guidelines.

Clinical Review: Medical Necessity Determinations

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Federal and State Legislature

• State Medicaid programs, definitions and terms of coverage

• Early Intervention and School-aged Programs

• CMS Local Coverage Determinations

Home State Health Plan

Specific Coverage

• Certificate of Benefits or other plan specific criteria

• Coordination of other ancillary services

Magellan Clinical Management

• Incorporate federal and state requirements, Home State Health Plan specific criteria and use of internally developed Clinical Guidelines and externally contracted, nationally recognized guidelines

• Specialty matched clinical experts perform clinical validation to ensure records support medical necessity, comply with standard clinical practice and appropriate billing practices

• Coordination of care amongst practitioners

• Peer-to-peer consultation opportunity prior to issuing an adverse determination

• Network-wide targeted outreach to in-need providers

Appeals &Consultations

Appeals and Reviewer Consultations

Administrative Denial If a request is closed for lack of clinical information received, records may be

submitted to NIA for review for determination without formal appeal.

Appeals Claim appeals are handled by Home State Health Plan.

Providers are required to submit a request for appeal to the plan upon receipt of claim denial.

Medical necessity appeals are managed by NIA or Health Plan (Please Confirm – Client Specific).

Follow the process outlined in the letter.

Re-review of an adverse determination is allowed within 2 business days.

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Provider Support

Additional Information for Providers

Members must be held harmless.

Procedures are evaluated based on established criteria. Clinical Guidelines are available on www.RadMD.com.

Clinical review process is conducted by NIA specialty matched peer reviewers.

Home State Health Plan may deny claims payments for services that:

did not meet criteria

did not receive sufficient or any clinical information

Medical necessity denials can be appealed through NIA. All other claims appeals are processed through Home State Health Plan.

NIA Customer Care Associates is available to assist providers at 800-424-5391.

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Provider Relations Contact Information

NIA Provider Relations Manager:

Name: Leta Genasci

Phone: 800-450-7281 Ext. 75518

Email: ljgenasci@magellanhealth.com

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Confidentiality Statement

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By receipt of this presentation, each recipient agrees that the information contained herein will be kept confidential and that the information will not be photocopied, reproduced, or distributed to or disclosed to others at any time without the prior written consent of Magellan Health, Inc.

The information presented in this presentation is confidential and expected to be used solely in support of the delivery of services to health plan members. By receipt of this presentation, each recipient agrees that the information contained herein will be kept confidential and that the information will not be photocopied, reproduced, or distributed to or disclosed to others at any time without the prior written consent of the health plan and Magellan Health, Inc.

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